9 ms·

It's not so much that we're not qualified to assess them, it's just that no one has invented portable X-ray (or CT, or MR...) glasses yet (I'm looking at you, G

It's not so much that we're not qualified to assess them, it's just that no one has invented portable X-ray (or CT, or MR...) glasses yet (I'm looking at you, Google!).

rdl 13y ago
Field portable x-ray (DR, even) and US is pretty widely available. Probably not something you'd put on even a normal ALS truck, but on expedition medicine or if you had to set up a facility in advance, were far from a permanent facility, etc. I've seen DR used for tb screening quite frequently (it avoids exposing the expensive radiologists to the field...); US for midwives for ob/gyn also makes a lot of sense, and I've seen those used with GSM or 3G backhaul of images to a radiologist. Probably the best use would be to have x-ray capability in the truck to verify placement of endotracheal tubes. Shooting an adequate chest film is something you can learn in 5-10 minutes (although, licensure requirements...). (I've seen fairly portable CT, but in the sense of "shipping container with 1-2 day setup"; there are of course the CT and MR imaging trucks too.)
- lostlogin 13y ago
  Adequate in 5-10. I doubt this. I have trained students for 10ish years. I have seen what very experienced ED nurses (and consultants, anaesthetists etc) do with their 'diagnosis' from films, despite numerous courses and flash qualifications. This is without taking the film. Do it for years, see lots of things, make lots of mistake and then you'll get good. Radiography students are generally competent for unsupervised chest radiography after about 6 months to a year. This is working 2 days a week, study for 3 days. You could probably produce a crap film but good enough to show ET tube in significantly less time, but a good operator has other ways to verify tube placement. Portable x-ray in bigger towns provides a great service to rest homes, prisons etc and is fiddly and laborious. It's a niche market. The same (but less common) with mobile MRI. CT must be done somewhere in a mobile fashion, I haven't seen it. It is easy to get a little twisted with terminology, but mobile x-ray generally means you push it around the hospital, portable meaning you carry it out the van, up the stairs, into the rest home (the 600kg mobile machine is not something you would carry easily).This terminology is widely abused though!
  - JshWright 13y ago
    Those are fairly common uses of 'mobile' and 'portable' in general (the 'mobile' radio is attached to the truck, the 'portable' radio is on your hip). As far as '5-10' goes... rdl wasn't talking about interpreting films, he was talking about shooting them (and then transmitting them to a doc somewhere for interpretation). There are some interpretations that could be taught in minutes . Most importantly, the one rdl mentioned, "Does that radio-opaque wire stay straight in the trachea, or does it deviate?". Edit: I'm not sure the comparison to ED nurses is apt. Paramedics and nurses do very different jobs.
    - lostlogin 13y ago
      Yes to you and RDL - I see the point. I do dispute the 5-10 minutes though, but the point was that it could be learnt relatively fast. I'd assume some sort of weight versus exposure factors chart would hold 80% of the knowledge and when combined with a set 180cm tube-film distance and a digital system (forgiving!), things would be learnt quite fast. It is deceptive how hard it is to get a patient properly straight, and thereby prevent ET looking deviated.
      - rdl 13y ago
        You could probably combine a CCD/CMOS imager (i.e. cheap webcam) with an x-ray (and maybe mm-wave imager or something) to help with this. Something like an AED as applied to radiology, with safety interlocks.
        lostlogin 13y ago
        It would definitely be possible to have very simple scans done by someone who was given a crash course training (knees, lumbar spines, brains). The problem is that the most complicated work always fails to advertise itself - I found a liver tumour yesterday while scanning a lumbar spine. It appeared on 1 image of the planning scan (a crap, low res image). The student was was present didn't see it and dismissed it as an artifact when I pointed it out, and she is a good student. I'm sure protocols could be made to avoid problems (send all imaging to the PACS, even the duds) like this however.
- JshWright 13y ago
  I was being a bit flippant in my initial post. I'm aware of (and quite excited about) the increased use of imaging (and various other labs) in the field. I expect in 5-10 years ultrasound will be quite common, and x-ray may not be too far behind (mostly for respiratory related stuff... tube confirmation, confirming pleural effusions, etc...)
  - rdl 13y ago
    What would be cool would be using telerad (and telemed in general) to let some combination of family-caregiver, EMT, Paramedic, NPs, and doctors do both initial and definitive care in the field; should be a lot lower cost, both because it's cheaper and because it's better (old/sick/etc. people not being transported and then exposed to a bunch of other sick people would be a big win.)
    - JshWright 13y ago
      I think (or at least hope) this is the direction medicine is headed in... In the early (Johnny and Roy) days, it was _all_ telemedicine (send the strip and start LR...). We slowly got away from that for a variety of reasons, and are just now heading back to it. While I'm not a huge fan of 'mother may I' medicine, I think it's crazy not to leverage the major advances in communications technology to bring a much broader range of specialties into the back of an ambulance. Some area are having a lot of success with Paramedic Practitioners. The idea being that the can a) handle 'routine' medical calls without a trip to the ER, and can b) make proactive welfare checks on known frequent fliers (brittle diabetics, etc), reducing the load on the EMS system in general. Obviously they're also available as advanced level providers when needed, but this gives them something to do (and bill for) in their downtime.
  - nobodysfool 13y ago
    Even with x-ray available to paramedics, they don't get the type of training needed to understand what they are seeing on an x-ray and even then they wouldn't have the training to correct any issues or authority to prescribe treatment. The best they could do is get a radiogram and pass it on, but even then, they usually are not in the best position to dose out radiation, nor would their patients likely sit still, since the idea is to get them to a hospital or care provider ASAP.
cdjk 13y ago
Probably one of the most common users of portable (ok, maybe I should say mobile) xrays are large animal veterinarians. I've seen them used with horses. Generally there's power at barns (someplace nearby, at least), but I imagine a generator would work.

It's not so much that we're not qualified to assess them, it's just that no one has invented portable X-ray (or CT, or MR...) glasses yet (I'm looking at you, Google!).

rdl 13y ago

Field portable x-ray (DR, even) and US is pretty widely available. Probably not something you'd put on even a normal ALS truck, but on expedition medicine or if you had to set up a facility in advance, were far from a permanent facility, etc. I've seen DR used for tb screening quite frequently (it avoids exposing the expensive radiologists to the field...); US for midwives for ob/gyn also makes a lot of sense, and I've seen those used with GSM or 3G backhaul of images to a radiologist. Probably the best use would be to have x-ray capability in the truck to verify placement of endotracheal tubes. Shooting an adequate chest film is something you can learn in 5-10 minutes (although, licensure requirements...). (I've seen fairly portable CT, but in the sense of "shipping container with 1-2 day setup"; there are of course the CT and MR imaging trucks too.)

lostlogin 13y ago
Adequate in 5-10. I doubt this. I have trained students for 10ish years. I have seen what very experienced ED nurses (and consultants, anaesthetists etc) do with their 'diagnosis' from films, despite numerous courses and flash qualifications. This is without taking the film. Do it for years, see lots of things, make lots of mistake and then you'll get good. Radiography students are generally competent for unsupervised chest radiography after about 6 months to a year. This is working 2 days a week, study for 3 days. You could probably produce a crap film but good enough to show ET tube in significantly less time, but a good operator has other ways to verify tube placement. Portable x-ray in bigger towns provides a great service to rest homes, prisons etc and is fiddly and laborious. It's a niche market. The same (but less common) with mobile MRI. CT must be done somewhere in a mobile fashion, I haven't seen it. It is easy to get a little twisted with terminology, but mobile x-ray generally means you push it around the hospital, portable meaning you carry it out the van, up the stairs, into the rest home (the 600kg mobile machine is not something you would carry easily).This terminology is widely abused though!
- JshWright 13y ago
  Those are fairly common uses of 'mobile' and 'portable' in general (the 'mobile' radio is attached to the truck, the 'portable' radio is on your hip). As far as '5-10' goes... rdl wasn't talking about interpreting films, he was talking about shooting them (and then transmitting them to a doc somewhere for interpretation). There are some interpretations that could be taught in minutes . Most importantly, the one rdl mentioned, "Does that radio-opaque wire stay straight in the trachea, or does it deviate?". Edit: I'm not sure the comparison to ED nurses is apt. Paramedics and nurses do very different jobs.
  - lostlogin 13y ago
    Yes to you and RDL - I see the point. I do dispute the 5-10 minutes though, but the point was that it could be learnt relatively fast. I'd assume some sort of weight versus exposure factors chart would hold 80% of the knowledge and when combined with a set 180cm tube-film distance and a digital system (forgiving!), things would be learnt quite fast. It is deceptive how hard it is to get a patient properly straight, and thereby prevent ET looking deviated.
    - rdl 13y ago
      You could probably combine a CCD/CMOS imager (i.e. cheap webcam) with an x-ray (and maybe mm-wave imager or something) to help with this. Something like an AED as applied to radiology, with safety interlocks.
      - lostlogin 13y ago
        It would definitely be possible to have very simple scans done by someone who was given a crash course training (knees, lumbar spines, brains). The problem is that the most complicated work always fails to advertise itself - I found a liver tumour yesterday while scanning a lumbar spine. It appeared on 1 image of the planning scan (a crap, low res image). The student was was present didn't see it and dismissed it as an artifact when I pointed it out, and she is a good student. I'm sure protocols could be made to avoid problems (send all imaging to the PACS, even the duds) like this however.
JshWright 13y ago
I was being a bit flippant in my initial post. I'm aware of (and quite excited about) the increased use of imaging (and various other labs) in the field. I expect in 5-10 years ultrasound will be quite common, and x-ray may not be too far behind (mostly for respiratory related stuff... tube confirmation, confirming pleural effusions, etc...)
- rdl 13y ago
  What would be cool would be using telerad (and telemed in general) to let some combination of family-caregiver, EMT, Paramedic, NPs, and doctors do both initial and definitive care in the field; should be a lot lower cost, both because it's cheaper and because it's better (old/sick/etc. people not being transported and then exposed to a bunch of other sick people would be a big win.)
  - JshWright 13y ago
    I think (or at least hope) this is the direction medicine is headed in... In the early (Johnny and Roy) days, it was _all_ telemedicine (send the strip and start LR...). We slowly got away from that for a variety of reasons, and are just now heading back to it. While I'm not a huge fan of 'mother may I' medicine, I think it's crazy not to leverage the major advances in communications technology to bring a much broader range of specialties into the back of an ambulance. Some area are having a lot of success with Paramedic Practitioners. The idea being that the can a) handle 'routine' medical calls without a trip to the ER, and can b) make proactive welfare checks on known frequent fliers (brittle diabetics, etc), reducing the load on the EMS system in general. Obviously they're also available as advanced level providers when needed, but this gives them something to do (and bill for) in their downtime.
- nobodysfool 13y ago
  Even with x-ray available to paramedics, they don't get the type of training needed to understand what they are seeing on an x-ray and even then they wouldn't have the training to correct any issues or authority to prescribe treatment. The best they could do is get a radiogram and pass it on, but even then, they usually are not in the best position to dose out radiation, nor would their patients likely sit still, since the idea is to get them to a hospital or care provider ASAP.

cdjk 13y ago

Probably one of the most common users of portable (ok, maybe I should say mobile) xrays are large animal veterinarians. I've seen them used with horses. Generally there's power at barns (someplace nearby, at least), but I imagine a generator would work.